Q1. A patient who lies completely still and resists any movement of the abdomen most likely has: A. Renal colic B. Peritonitis C. Biliary colic D. Gastroenteritis ANSWER: B — peritonitis. Why: parietal peritoneal inflammation makes movement painful, so the patient stays motionless. Colic causes restlessness — the patient cannot find a comfortable position. LEARNING POINT: this is visible from the end of the bed, before examination.

Q2. Which is the commonest cause of SMALL bowel obstruction? A. Colorectal cancer B. Adhesions C. Volvulus D. Diverticular stricture ANSWER: B — adhesions. Why: post-surgical adhesions are the commonest cause of small bowel obstruction, followed by hernias. Cancer and volvulus are commoner causes of LARGE bowel obstruction. LEARNING POINT: ask about previous abdominal surgery, and always examine the hernial orifices.

Q3. A 76-year-old with atrial fibrillation has severe central abdominal pain but a soft, minimally tender abdomen. Lactate 5.1. The most likely diagnosis is: A. Gastroenteritis B. Acute mesenteric ischaemia C. Constipation D. Anxiety ANSWER: B — mesenteric ischaemia. Why: pain out of proportion to examination findings, in a patient at embolic risk, with a raised lactate. The abdomen is soft early because the parietal peritoneum is not yet involved. LEARNING POINT: a benign abdomen is a FEATURE of early mesenteric ischaemia, not evidence against it.

Q4. A patient with adhesional obstruction managed conservatively develops constant rather than colicky pain, tenderness and a rising lactate. This indicates: A. Improvement B. Strangulation requiring urgent surgery C. Constipation D. Opioid side effects ANSWER: B — strangulation. Why: colic reflects peristalsis against an obstruction. Constant pain with tenderness and rising lactate indicates compromised blood supply and dying bowel. LEARNING POINT: this is the point at which conservative management must stop.

Q5. A 19-year-old with severe abdominal pain, guarding and vomiting is found to have glucose 26 mmol/L and raised ketones, with deep rapid breathing. The correct action is: A. Immediate laparotomy B. Treat the DKA and reassess the abdomen C. Discharge with analgesia D. Oral rehydration only ANSWER: B. Why: diabetic ketoacidosis causes abdominal pain severe enough to mimic a surgical abdomen, and the tachypnoea is Kussmaul respiration. Pain from ketoacidosis settles as the metabolic state corrects; surgical pain does not. LEARNING POINT: reassessment after treatment distinguishes the two without an unnecessary operation.

Q6. A 73-year-old man has sudden severe left flank pain radiating to the groin, his first such episode, with BP 100/60. Before accepting "renal colic" you must exclude: A. Urinary tract infection B. Leaking abdominal aortic aneurysm C. Constipation D. Musculoskeletal pain ANSWER: B — leaking aortic aneurysm. Why: it closely mimics renal colic, and a FIRST episode of colic in this age group is unusual. The borderline blood pressure adds concern. Missing it is a recognised cause of preventable death. LEARNING POINT: examine for a pulsatile expansile mass and image before the label sticks.

Q7. Regarding analgesia in the undiagnosed acute abdomen: A. Opioids must be withheld until a surgeon has examined the patient B. Adequate analgesia should be given; it does not mask the diagnosis C. Only paracetamol is permitted D. Analgesia prevents accurate examination ANSWER: B — give adequate analgesia. Why: the traditional teaching that opioids obscure abdominal signs is not supported by evidence. Pain relief makes examination easier and is a basic standard of care. LEARNING POINT: a patient writhing in agony cannot be examined properly anyway.